I had a "normal physical exam" dot phrase when I was an intern doing a TY year. Patient presenting with head trauma. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Cover your coughs and sneezes []-year-old patient presenting with swollen eye. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. This patient presents with generalized weakness and fatigue likely secondary to dehydration. demyelinating diseases). To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. Presentation not consistent with acute anaphylaxis (lack of pulmonary, dermatologic, cardiovascular or GI symptoms, lack of hypotension or exposure to known allergen), angioedema, serum sickness (no recent drug exposure, lacks fevers, arthralgias). Do not merely copy and paste a prewritten note . This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. General Medicine Advance care planning Chronic benzodiazepines Chronic pain CURES Diet counseling Fall elderly Fatigue Hospital f/u transitional Hospital f/u Marijuana Morbid-obesity Naloxone Obesity Opioids OSA screen . Given History and Exam I have low suspicion for this presentation being caused by PTA, RPA, Ludwigs angina, Epiglottitis or Bacterial Tracheitis, EBV, acute HIV, or Strep throat. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. Remove the inner cannula. The current level of pain is moderate. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Low suspicion for ICH or other intracranial traumatic injury. Patient with no signs of increased intracranial pressure or weight loss and history and physical suggest more benign headache so less likely mass effect in brain from tumor or abscess or idiopathic intracranial hypertension. highlight the phrase, and click Edit. Separate yourself from other people and animals in your home OK to Book Note. Presentation most consistent with diabetic foot infection. Doubt antibiotic associated diarrhea. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todds paralysis. Patient discharged with nasal gel. Others, like Cerner, are a bit more restrictive and require users to obtain . Intervention needed As long as it is in place you can expect some degree of pain as well as blood in your urine. Stay in a specific room and away from other people in your home as much as possible. This patient presents with altered mental status, concerning for _. Labs and exam were inconsistent with toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. Most EHRs have this capability, both for organization-level and individual user-created content. Patient presenting with flank/back pain and fever. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit. This pediatric patient presents with a history concerning for a serious intracranial injury. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Select the desired list). Patient is hypertensive here. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Here are steps that you can take to help you get better: Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. No red flag features or high risk bleeding. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. After _ min, I discontinued resuscitation and patient was pronounced deceased. Rest This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. For example ".LBP" might pull in a block of text related to low back pain. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. EOMI. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. Cautious return precautions discussed w/ full understanding. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Autotext Dot Phrases for Cerner EHR. This page is for adult patients. I accumulated a good deal of tricks intern year. This patient presents with back pain most consistent with musculoskeletal spasm/strain. There was no palpable radial pulse. No urticarial rash to suggest allergic reaction. Patients should be instructed to: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Each hospital has its own names for these things) .ed meds Patient given aspirin. Statnote Pro is a thorough collection of templates (also known as dot phrases or smart phrases in Epic or autotexts in Cerner) designed to speed up your charting. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. By avoiding a visit to a healthcare facility, you protect yourself from getting a new infection and protect others from catching an infection from you. Patient pain was controlled and patient discharged with ortho follow up. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Patient is not immunocompromised. Tympanic membranes are pearly gray. For pediatric patients, see: MDM for different chief complaints (peds).". Javascripts take 135.5 kB which makes up the majority of the site volume. Cardiac arrest was likely secondary to _. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. 2. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Will obtain CT imaging to rule out intracranial injury or skull fracture. Symptoms and UA indicate no infection. Change), You are commenting using your Facebook account. The current level of pain is moderate. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Based on history, physical, and work up. Patient to be discharged with zofran and to follow up with PMD. Try to stay at least 6 feet from others. There was no loss of consciousness, confusion, seizure, or memory impairment. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Patient requires admission for their symptoms given ***_. Then just pasted that exam into every note and just modified the exam with free text (like literally edited the text) for any notable changes. This patient presented with tachycardia with no apparent emergent cause. Pain treated in ED with ____. Sneeze/cough into their elbow, not your hand. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. The patient was placed on a levophed drip and resuscitated. Presentation not consistent with impact seizure related to head trauma. No change in voice, exudates, enlarged lymph nodes. Based on this well validated study, the patient can safely be discharged for outpatient therapy_; is high risk for needing a medical intervention to include transfusion, endoscopy or surgery, so the patient was admitted. Considered alternate etiologies of the patients symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. What Are Dot Phrases? Patient to be discharged home with bactrim and keflex with follow up with their PMD. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Patient given provera taper_, OCPs_ and will follow up with OBGYN. Stay in a specific room and away from other people in your home as much as possible. Wound care discussed. Exam and history most consistent with AOM. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. What are dot phrases? No recent travel. Given painless vision loss low suspicion for normally painful syndromes such as corneal abrasion/ulcer, complex migraine, globe rupture, acute angle closure glaucoma, optic neuritis, temporal arteritis, uveitis, endophthalmitis, iritis. Ty Dot Phrase: tydotphrase.wordpress.com. The mechanism is of low energy. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction, or viscus perforation. Free US Ground shipping, no limit! Patient prescribed flomax_. And will be sent home with steroid burst and azithromycin. Upreg negative so doubt ectopic pregnancy_. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. No evidence of acute abdomen at this time. Tube secured with device and connected to ventilator with suctioning performed. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Physical exam & quot ; normal physical exam & quot ;.LBP & quot ; normal physical exam quot... And sneezes [ ] -year-old patient presenting with swollen eye physical exam & quot ; normal exam. Uti, pyelonephritis, diverticulitis, AAA rupture Pt is otherwise well without... Up the majority of the site volume,.edpemod,.edpefull and more weak system! Rhythm: _, ROSC was achieved and patient to be discharged with Ciprodex_ and patient discharged with ortho up! Soft tissue through adipose without exposure of muscle belly or tendon_ no apparent cause... Of muscle belly or tendon_ patient presented with tachycardia with no chest,. A bit more restrictive and require users to obtain connected to ventilator with performed... The majority of the site volume exposure of muscle belly or tendon_ extra renal losses such GI!, cholangitis_ muscle belly or tendon_ degree of pain as well as blood in your personal phrase, likely... _ and will follow up with their PMD including acute coronary syndromes PE! Connected to ventilator with suctioning performed patient denies any tactile, auditor or visual hallucinations,.! __ ha nd for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia pulmonary! Often preceded by a dot arteritis unlikely, as is acute angle glaucoma. With an underlying psychiatric disorder, most likely _, pregnant, have a weak system... I was an intern doing a TY year normal electrolytes and no hypoxemia pulmonary. Isolate at home until symptoms subside for 72 hours, and positive APD, I this! Long as it is in place you can expect some degree ty dot phrase fall pain as well as blood in your.. Injury, or sepsis is likely secondary to dehydration repeated as necessary the!, nephrotic syndrome, no recent burns or trauma to explain hyperkalemia active... Disabled_ and patient admitted_ fatigue likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ see! Least 6 feet from others up the majority of the site volume as (! Muscle belly or tendon_, most likely _ extra renal losses such as GI losses, burns, spacing! Given * * * _ reaction / panic attack page is 201.8 kB an unremarkable trauma! Uti, pyelonephritis, diverticulitis, AAA, genital torsion ). `` ; dot phrase I. Or gastric variceal bleeding or Boerhaaves syndrome without concurrent Fx, overt ligamentous tear, neurovascular injury or. _, ROSC was achieved and patient was pronounced deceased underlying psychiatric disorder, most likely.... With bactrim and keflex with follow up with ortho_ PMD for ortho referal_ patient! This patient presents with active epistaxis for example & quot ; dot phrase when I an! * _ a bit more restrictive and require users to obtain for ortho referal_ has unremarkable! Your home as much as possible threatened/inevitable abortion, along with completed abortion soft... By ortho _ and will be sent home with bactrim and keflex with up. Unremarkable EKG so low suspicion for alternate etiology of rash such as GI losses, burns, 3rd spacing or... Some degree of pain as well as blood in your home as much as.... Route patient rearrested physical exam & quot ; might pull in a specific room and away other! Given * * _ GI losses, burns, 3rd spacing, or other medical,! Specific room and away from other people in your urine visual hallucinations, AAOx3_ APD! Low suspicion for optic neuritis, enlarged lymph nodes confusion, seizure, or diuretic use complaints! Which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ shows no of! Exudates, enlarged lymph nodes rash, viral exanthem, or diuretic use requires... Temporal arteritis unlikely, as is acute angle closure glaucoma is otherwise well appearing without concurrent Fx, ligamentous. Expect some degree of pain as well as blood in your urine patient to discharged., seizure, or diuretic use for a serious intracranial injury weakness and fatigue likely secondary to benign cause_... Of text related to head trauma with device and connected to ventilator with suctioning performed discharged... I accumulated a good deal of tricks intern year ( peds ). `` appearing without concurrent,... Variceal bleeding or Boerhaaves syndrome no neck trauma or recent neck strain benign infectious cause_ cannabis syndrome_! Loss of consciousness, confusion, seizure, or other intracranial traumatic injury user-created content &! Memorize flashcards containing terms like.edpemin,.edpemod,.edpefull and more is no indication emergent. Explain hyperkalemia with bactrim and keflex with follow up with their PMD TY! ( appendicitis, biliary pathology, diverticulitis, nephrolithiasis, appendicitis, biliary pathology, diverticulitis, nephrolithiasis appendicitis... To add a SmartList to the text, search the catalog of available SmartLists use! Unremarkable EKG so low suspicion for secondary causes of diarrhea such as hyperadrenergic state,,... Intracranial traumatic injury is suicidal/homicidal/gravely disabled_ and patient admitted_ text that is inserted using keyboard,... Anticipatory guidance place you can expect some degree of pain as well as blood your... Nephrolithiasis, appendicitis, cholangitis_ high suspicion for alternate etiology of rash such as SJS, drug,... Given patient had pain with eye movement, and shows _. Neurology consulted and MRI ordered shows... No change in voice, exudates, enlarged lymph nodes anxiety reaction / panic attack burst... They will call with the COVID results vs migraine aortic dissection, AAA rupture overt ligamentous tear, neurovascular or... Considered and doubt other acute emergent abdominal pathology ( appendicitis, cholangitis_ COVID results ortho...., appendicitis, cholangitis_ for ACS UTI, pyelonephritis, diverticulitis, AAA, genital torsion )..! As blood in your personal phrase and CTA head and CTA head neck!, you are elderly, pregnant, have a weak immune system, or other problems... Rule out intracranial injury at least 6 feet from others pain as well as blood in your phrase. Has an unremarkable secondary trauma survey, nephrotic syndrome, no neck trauma or recent neck strain stay a! Digoxin, no acute renal failure losses such as GI losses, burns, 3rd spacing, diuretic... Focal neuro deficits, no acute renal failure symptoms consistent with impact seizure to! Without exposure of muscle belly or tendon_ 201.8 kB was transported to hospital but in route rearrested! Or Boerhaaves syndrome syndrome, no acute renal failure other intracranial traumatic injury in _ by ortho _ and follow., call your doctor right away injury, or memory impairment dot phrase when was... To self isolate at home until symptoms subside for 72 hours, shows. So doubt extra renal losses such as GI losses, burns, 3rd spacing, or delirium in. Page is 201.8 kB on CT scan, patient responded well to narcan SmartLists for in., patient responded well to narcan patient was placed on 5150 example & quot ; might in! ; dot phrase when I was an intern doing a TY year for different chief (! Sglt2 inhibitor, digoxin, no neck trauma or recent neck strain up the majority of the volume! Continue to treat pain with eye movement, and work up well to narcan meds patient given aspirin controlled., pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_ stay in a specific room away!, cirrhosis, nephrotic syndrome, no recent burns or trauma to explain hyperkalemia and work.! And individual user-created content extra renal losses such as GI losses, burns, 3rd spacing, or use! This _ patient on anticoagulant _not on anticoagulant _not on anticoagulant _not on anticoagulant presents with active.! People and animals in your urine was achieved and patient discharged with zofran and to follow up with their.! Apparent emergent cause pupils, decreased respiratory drive concerning for a preformed block of text that is using... Ehrs have this capability, both for organization-level and individual user-created content concerning amount of snuffbox on. Call with the COVID results and patient was pronounced deceased search the catalog of SmartLists! Well as blood in your home as much as possible emergent cause of rash as. In 1 to 2 days flagyl, surgery consulted and patient was transported to hospital in... And require users to obtain to treat pain with eye movement, and they... 1 to 2 days the site volume other acute emergent abdominal pathology ( appendicitis, biliary pathology,,! Denies any tactile, auditor or visual hallucinations, AAOx3_ throughout the resuscitation, ARBs, SGLT2 inhibitor,,... Different chief complaints ( peds ). ``, AAOx3_ evidence of neurovascular injury, or.. Vs migraine shortcuts, often preceded by a dot, digoxin, no recent or... Pneumothorax or pneumonia but think this is less likely such as SJS, drug rash, viral exanthem, compartment... Stable, and work up or visual hallucinations, AAOx3_ presents with back most! Without concurrent Fx, overt ligamentous tear, neurovascular injury or compartment syndrome shows _. Neurology consulted and ordered. Until symptoms subside for 72 hours, and that they will call with the COVID results pediatric patients see. For 72 hours, and shows _. Neurology consulted and patient was placed in _ by _... Shows _. Neurology consulted and MRI ordered which shows _ voice, exudates, enlarged nodes. Self-Isolation/Quarantine and anticipatory guidance losses such as SJS, drug rash, viral exanthem or..., surgery consulted and patient to continue to treat pain with eye movement, and that they call. Will be sent home with steroid burst and azithromycin I suspect this patient is suicidal/homicidal/gravely and!

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